18 Sep 2014 Brian Christopher Dalrymple · Prevention of Future Deaths report West London
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Concerns raised 6 Absence of a comprehensive and accessible computerised clinical record for each detainee View source Employment of medical practitioners without knowledge necessary to their role View source Inadequate routine medical assessment of segregated detainees View source Lack of detention staff awareness and recognition of mental-health indicators View source Failure to actively communicate relevant observations to healthcare staff View source Failure to bring potential mental-health indicators to responsible healthcare staff View source See 3 more concerns
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Brian Christopher Dalrymple · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The GEO Group UK Ltd; that does not assign responsibility.
PFD Monitor interpretation Absence of a comprehensive and accessible computerised clinical record for each detainee
Wider context from the report “(5)
The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The GEO Group UK Ltd; that does not assign responsibility.
PFD Monitor interpretation Employment of medical practitioners without knowledge necessary to their role
Wider context from the report “(3)
Medical practitioners may be employed at Harmondsworth IRC without knowledge necessary to that role.
The locum GP who gave evidence at the inquest was unaware of Detention Centre Rules 2001 or of the duties imposed on him- rule 35, for example. He was also unaware that healthcare staff had access to wing history documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The GEO Group UK Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate routine medical assessment of segregated detainees
Wider context from the report “(4)
Routine medical visits to segregated detainees are inadequate properly to assess detainees' healthcare needs.
The evidence was that each detainee would be asked through the wicket “Any medical problems?”, and if the answer was negative, there would be no further interaction- witness ████████ described the practice as “not fit for purpose” ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The GEO Group UK Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of detention staff awareness and recognition of mental-health indicators
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia ; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The GEO Group UK Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to actively communicate relevant observations to healthcare staff
Wider context from the report “(2)
Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.
In the present case, custody officers' entries in wing history records were sufficient (alone or in combination) to alert a reader to the possibility of mental health issues affecting Mr Dalrymple whilst detained at Harmondsworth IRC; these indicators were missed. In the terms of Witness ████████ the overall picture of developing (relapsing) mental disorder was not available to any one set of people.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The GEO Group UK Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to bring potential mental-health indicators to responsible healthcare staff
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No practicable steps can be taken concerning Harmondsworth working practices because management responsibility transferred to Mitie.
Verbatim wording from the response “As the Contract for the management of Harmondsworth IRC passed to Mitie on 01st September 2014, there is of course no practicable steps GEO can take in relation to the working practices at Harmondsworth.” Source location 2014-0410-Response-by-The-GEO-Group-UK-Ltd
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations